The Bitter Pill

Buprenorphine could end heroin addiction, curb disease, and cut crime. But bureaucrats, doctors, and much of the treatment industry are just saying no. A case study in why the best technology doesn't always win.

An opportunity to bring addiction treatment back into the mainstream appeared when lawmakers amended the Harrison Act in 2000 to enable bupe to come to market. It made a step in that direction by allowing general practitioners to prescribe the new drug. Yet it barred methadone clinics from prescribing the pill at all. This set the stage for some treatment centers to view private-practice physicians as rivals. Yale's David Fiellin, who attended several early training courses, recalls clinic workers standing up to share horror stories about hardcore addicts and suggesting that family physicians, if they prescribed the new drug, could expect the same in their waiting rooms.

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After bupe had been on the market a year, the law was amended to permit methadone clinics to prescribe it, but only under the same rules used for methadone (one dose per visit), which erases one of bupe's major advantages - that you don't have to schlep to a clinic every day. Meanwhile, many methadone providers have remained openly skeptical of the new med, fearing that it will further stigmatize methadone, or siphon off their most stable patients. The government reimburses methadone programs for the number of patients they oversee, not for the specific services they provide, so the payment for a stable patient who takes a dose and goes to work subsidizes treatment for more fragile clients with multiple addictions, mental illness, housing and unemployment issues, and more.

The regulatory problems didn't stop there. Influenced by tales of unscrupulous methadone clinics taking on huge case-loads for the reimbursement cash, Congress barred doctors from maintaining more than 30 bupe patients at a time. And in a monumental blunder, the law classified giant HMOs like Kaiser Permanente, as well as hospitals, as single providers, with the same 30-patient cap that Kolodny has in the solo practice he maintains on evenings and weekends. Four years later, the law remains unchanged. One clear sign of the law's unintended consequences: The world-renowned Addiction Institute of New York (better recognized by its old name, Smithers) doesn't mention bupe in its advertising because with a 30-patient limit, it fears it would have to turn people away.

Meanwhile, even private-practice physicians open-minded enough to seek bupe training find that it reinforces old stereotypes. "The courses are a disaster," says Columbia's Herbert Kleber, who has a contract from the federal Center for Substance Abuse Treatment to redesign the curriculum. The classes rely on scenarios instead of letting doctors interact with live patients - who tend not to be the monsters that many doctors imagine, Kleber says. The message that comes across? "Addicts are a difficult group to deal with. They'll rob your office blind and steal your nurse's purse," Kleber says, frowning. "You're a general practitioner: Tell me if you're going to prescribe."

The result is that bupe faces an uphill battle to find its way into doctors' offices.

Kolodny steers a big government sedan through the busy streets of Queens, past a billboard that promises, somewhat disturbingly, The World's Boldest Corrections Officers, then over the bridge to Rikers Island, where he'll talk about bupe to a group of prison docs and nurses. "Best-case scenario, everyone hears my speech and thinks this is an amazing treatment," he says. "But they may not want to be innovators. They may be content in what they're doing." What they're doing is maintaining inmates on methadone, trying to tame their addictions before they return to the street. Kolodny hopes that with the enticement of meds donated by Reckitt Benckiser - seed drugs - the prison will agree to put some inmates on bupe instead. Then, when they check out, they can tell their neighbors about it and increase the pressure on local doctors to write prescriptions.

A security escort leads Kolodny through two guard stations and a razor-wire fence that stands between roughly 17,000 inmates and a postcard view of the Manhattan skyline. He hands Kolodny a visitor ID - "Lose this and I'll fucking kill you," he instructs - and asks what brings him to Rikers. "You're talking about replacing methadone?" he says, skeptically, before Kolodny corrects him. "We're pretty anal about change here," the guard warns. "We don't like change."

A group of 25 doctors and nurses is already waiting when Kolodny arrives at the prison's health offices. He surveys the collection of bored, tired faces staring back at him, shuffles his notes, and begins. "With any new medication with significant advantages, you'd see ads on TV, like you do with Zoloft, you'd see ads in journals, docs would start prescribing it," Kolodny says. That obviously hasn't happened with bupe.

The doctors ask about side effects. Good news there. They ask whether it shows up on a drug screen (methadone does, so many people who might face a urine test at work avoid it). Nope, Kolodny says, a bupe patient's urine tests negative - more good news. They ask about the potential for black-market dealing; inmates learn to hold their methadone in their throat, spit it back up, and sell the spit. That's pretty much impossible, Kolodny says, to nods of approval. Will inmates be able to keep receiving bupe after they leave prison? Some, but not all, Kolodny says. That's because of the nearly 300 doctors in New York licensed to prescribe bupe, only a handful will accept Medicaid, even though it covers the treatment. Any more - well, the city is working on it.

As he leaves through the tall, steel gates, Kolodny breaks into a smile. "I didn't think people would greet us this warmly," he says, genuinely surprised. "I don't know if I'd go so far as to say we achieved buy-in, but it was a start."

On the drive back to his office downtown, Kolodny's Treo rings twice, just minutes apart. Two more people looking for bupe treatment at his private practice. "That's weird," he laughs. Or, maybe, an encouraging sign.